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BackgroundWe investigated the associations of healthcare worker status with multisystem illness trajectory in hospitalised post-COVID-19 individuals.Methods and resultsOne hundred and sixty-eight patients were evaluated 28–60 days after the last episode of hospital care. Thirty-six (21%) were healthcare workers. Compared with non-healthcare workers, healthcare workers were of similar age (51.3 (8.7) years vs 55.0 (12.4) years; p=0.09) more often women (26 (72%) vs 48 (38%); pIn adjusted multivariate logistic regression analysis, healthcare worker status associated with a binary classification (probable/very likely vs not present/unlikely) of adjudicated myocarditis (OR: 2.99; 95% CI (1.01 to 8.89) by 28–60 days postdischarge).After a mean (SD, range) duration of follow-up after hospital discharge of 450 (88) days (range 290, 627 days), fewer healthcare workers died or were rehospitalised (1 (3%) vs 22 (17%); p=0.038) and secondary care referrals for post-COVID-19 syndrome were common (42%) and similar to non-healthcare workers (38%; p=0.934).ConclusionHealthcare worker status was independently associated with the likelihood of adjudicated myocarditis, despite better antecedent health. Two in five healthcare workers had a secondary care referral for post-COVID-19 syndrome.Trial registration numberNCT04403607.

Background: The pathophysiology and trajectory of multiorgan involvement in post-COVID-19 syndrome is uncertain. Methods: A prospective, multicenter, longitudinal, cohort study involving post-COVID-19 patients enrolled in-hospital or early post-discharge (visit 1) and re-evaluated 28-60 days post-discharge (visit 2). Multisystem investigations included chest computed tomography with pulmonary and coronary angiography, cardiovascular and renal magnetic resonance imaging, digital electrocardiography, and multisystem biomarkers. The primary outcome was the adjudicated likelihood of myocarditis.Results: 161 patients (mean age 55 years, 43% female) and 27 controls with similar age, sex, ethnicity, and vascular risk factors were enrolled from 22 May 2020 to 2 July 2021 and had a primary outcome evaluation. Compared to controls, at 28-60 days post-discharge, patients with COVID-19 had persisting evidence of cardio-renal involvement, systemic inflammation, and hemostasis pathway activation. Myocarditis was adjudicated as being not likely (n=17; 10%), unlikely (n=56; 35%), probable (n=67; 42%) or very likely (n=21; 13%). Acute kidney injury (odds ratio, 95% confidence interval: 3.40 (1.13, 11.84); p=0.038) and low hemoglobin A1c (0.26 (0.07, 0.87); p=0.035) were multivariable associates of adjudicated myocarditis. During convalescence, compared to controls, COVID-19 was associated with worse health-related quality of life (EQ5D-5L) (pConclusions: The illness trajectory of COVID-19 includes persisting cardio-renal inflammation, lung damage and hemostasis activation. Adjudicated myocarditis occurred in one in eight hospitalized patients and was associated with impairments in health status, physical and psychological wellbeing during community convalescence. Public registration: ClinicalTrials.gov identifier is NCT04403607.

Background: Sodium-glucose cotransporter 2 inhibitors reduce the risk of heart failure hospitalization and cardiovascular death in patients with heart failure and reduced ejection fraction (HFrEF). However, their effects on cardiac structure and function in HFrEF are uncertain. Methods: We designed a multicenter, randomized, double-blind, placebo-controlled trial (the SUGAR-DM-HF trial [Studies of Empagliflozin and Its Cardiovascular, Renal and Metabolic Effects in Patients With Diabetes Mellitus, or Prediabetes, and Heart Failure]) to investigate the cardiac effects of empagliflozin in patients in New York Heart Association functional class II to IV with a left ventricular (LV) ejection fraction ≤40% and type 2 diabetes or prediabetes. Patients were randomly assigned 1:1 to empagliflozin 10 mg once daily or placebo, stratified by age ( Results: From April 2018 to August 2019, 105 patients were randomly assigned: mean age 68.7 (SD, 11.1) years, 77 (73.3%) male, 82 (78.1%) diabetes and 23 (21.9%) prediabetes, mean LV ejection fraction 32.5% (9.8%), and 81 (77.1%) New York Heart Association II and 24 (22.9%) New York Heart Association III. Patients received standard treatment for HFrEF. In comparison with placebo, empagliflozin reduced LV end-systolic volume index by 6.0 (95% CI, –10.8 to –1.2) mL/m 2 ( P =0.015). There was no difference in LV global longitudinal strain. Empagliflozin reduced LV end-diastolic volume index by 8.2 (95% CI, –13.7 to –2.6) mL/m 2 ( P =0.0042) and reduced N-terminal pro-B-type natriuretic peptide by 28% (2%–47%), P =0.038. There were no between-group differences in other cardiovascular magnetic resonance measures, diuretic intensification, Kansas City Cardiomyopathy Questionnaire Total Symptom Score, 6-minute walk distance, or B-lines. Conclusions: The sodium-glucose cotransporter 2 inhibitor empagliflozin reduced LV volumes in patients with HFrEF and type 2 diabetes or prediabetes. Favorable reverse LV remodeling may be a mechanism by which sodium-glucose cotransporter 2 inhibitors reduce heart failure hospitalization and mortality in HFrEF. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03485092.

Background COVID-19 is typically a primary respiratory illness with multisystem involvement. The prevalence and clinical significance of cardiovascular and multisystem involvement in COVID-19 remain unclear. Methods This is a prospective, observational, multicentre, longitudinal, cohort study with minimal selection criteria and a near-consecutive approach to screening. Patients who have received hospital care for COVID-19 will be enrolled within 28 days of discharge. Myocardial injury will be diagnosed according to the peak troponin I in relation to the upper reference limit (URL, 99th centile) (Abbott Architect troponin I assay; sex-specific URL, male: >34 ng/L; female: >16 ng/L). Multisystem, multimodality imaging will be undertaken during the convalescent phase at 28 days post-discharge (Visit 2). Imaging of the heart, lung, and kidneys will include multiparametric, stress perfusion, cardiovascular magnetic resonance imaging, and computed tomography coronary angiography. Health and well-being will be assessed in the longer term. The primary outcome is the proportion of patients with a diagnosis of myocardial inflammation. Conclusion CISCO-19 will provide detailed insights into cardiovascular and multisystem involvement of COVID-19. Our study will inform the rationale and design of novel therapeutic and management strategies for affected patients. Clinical trial registration ClinicalTrials.gov identifier NCT04403607.

Background Current guidelines do not recommend routine assessment of right atrial volume due to the lack of standardized data. Three-dimensional wall-motion tracking (3D-WMT) is a new technology that allows us to calculate volumes without any geometric assumptions. The aim of this study was to define the indexed reference values for two-dimensional echocardiography (2D-echo) and 3D-WMT in adult healthy population and to assess the intermethod, intra- and interobserver agreement. Methods Prospective study. Nonselected healthy subjects were enrolled. Every patient underwent a 2D-echo and a 3D-WMT examination. 2D-echo right atrial volume was obtained by using the area-length method (A-L) from four- and two-chamber view. 3D-echo volumes were assessed by 3D-WMT. Values were indexed by the patient's body surface area. Results Sixty consecutive healthy subjects were enrolled. Mean age was 57 ± 12-years old and 27 patients (45%) were male. Average indexed right atrial volume obtained by 2D-echo and 3D-echo was 16.76 ± 8.15 mL/m2 and 19.05 ± 6.87 mL/m2, respectively. Univariate linear regression analysis between 2D-echo and 3D-echo right atrial volumes shows a weak correlation between right atrial volume obtained with 2D-echo compared with 3D-WMT (r = 0.29, CI 95% 0.029–0.66, P = 0.033). The agreement analysis shows a similar result (intraclass correlation coefficient [ICC] = 0.28). The intra- and interobserver agreement analysis showed a better agreement when using 3D-WMT. Conclusions This is the first study that reports the reference indexed right atrial volume values by means of 2D-echo and 3D-echo in healthy population. 3D-WMT is a feasible and reproducible method to determine right atrial volume.

Objectives This study sought to assess the long-term clinical outcome of patients with spontaneous coronary artery dissection (SCD) managed with a conservative strategy. Background SCD is a rare, but challenging, clinical entity. Methods A prospective protocol, including a conservative management strategy, was followed. Revascularization was only considered in cases with ongoing/recurrent ischemia. Inflammatory/immunologic markers were systematically obtained. Results Forty-five consecutive patients (incidence 0.27%) were studied during a 6-year period. Of these, 27 patients (60%) had “isolated” SCD (I-SCD), and 18 had SCD associated with coronary artery disease (A-SCD). Age was 53 ± 11 years, and 26 patients were female. Most patients presented with an acute myocardial infarction. SCD had a diffuse angiographic pattern (length: 31 ± 23 mm). In 11 patients, the diagnosis was confirmed by intracoronary imaging techniques. Sixteen patients (35%) required revascularization during initial admission. One patient died after surgery, but no additional patient experienced recurrent myocardial infarction. No significant inflammatory/immunologic abnormalities were detected. At follow-up (median 730 days), only 3 patients presented with adverse events (1 died of congestive heart failure, and 2 required revascularization). No patient experienced a myocardial infarction or died suddenly. Event-free survival was similar (94% and 88%, respectively) in patients with I-SCD and A-SCD. Notably, at angiographic follow-up, spontaneous “disappearance” of the SCD image was found in 7 of 13 (54%) patients. Conclusions In this large prospective series of consecutive patients with SCD, a “conservative” therapeutic strategy provided excellent long-term prognosis. Clinical outcome was similar in patients with I-SCD and A-SCD. The natural history of SCD includes spontaneous healing with complete resolution.

ObjectivesThis study sought to assess the diagnostic value of optical coherence tomography (OCT) in patients with suspected spontaneous coronary artery dissection (SCAD).BackgroundSCAD is a rare but challenging clinical entity.MethodsFollowing a prospective protocol, OCT was performed in 17 consecutive patients with a clinical and angiographic suspicion of SCD from a total of 5,002 patients undergoing coronary angiography. A conservative management strategy was followed.ResultsOCT ruled out the diagnosis of SCAD in 6 patients with coronary artery disease (atherosclerotic plaques and/or intracoronary thrombus). In 11 patients (age 48 ± 9 years, 9 female), OCT confirmed the presence of SCAD. A double-lumen or intramural hematoma image was visualized in all cases. However, only 3 patients presented an intimal “flap” on angiography. OCT readily identified the intimal rupture site (n = 7), the thickness (348 ± 84 μm) and length (31 ± 9 mm) of the intimomedial membrane, the area of the true (1.1 ± 0.5 mm2) and false lumen (5.9 ± 2.1 mm2), the associated intramural hematoma (n = 9), and thrombi in the true or false lumens (n = 11). Most of these findings were angiographically silent. After stenting (n = 4), OCT disclosed adequate stent coverage, expansion, and apposition, but also residual intramural hematoma at the stented site (abluminal) and at the distal vessel.ConclusionsOCT provides unique insights in patients with SCAD that allow an early diagnosis and adequate management. Most of these findings are undetectable by angiography.

The echocardiographic technology known as three-dimensional wall motion tracking offers three-dimensional images of the myocardium and provides multiple measures of deformation, one of which is known as “area strain” (AS), which combines left ventricular longitudinal and circumferential deformations. Our aim was to describe the normal maximum systolic reference AS value in a sample of healthy subjects. Sixty consecutive subjects without known cardiovascular risk factors or diseases were enrolled, and left ventricular AS was measured. Overall mean AS was –38.87 ± 5.89%. Mean values at the level of the basal, middle, and apical segments were –38.42% ± 7.58%, –38.74% ± 6.34%, and −43.18% ± 12.81%, respectively. Thus, our results show for the first time the reference values for AS in healthy subjects.

Resumen La tecnologia ecocardiografica denominada three-dimensional wall motion tracking es capaz de realizar un seguimiento tridimensional del miocardio y obtener multiples valores de su deformacion, entre los que se encuentra el area strain (AS), que combina el analisis de la deformacion longitudinal y circunferencial del ventriculo izquierdo. Nuestro objetivo es describir el valor sistolico maximo normal de referencia de AS en una muestra de sujetos sanos. Se recluto a 60 sujetos consecutivos, sin enfermedad ni factores de riesgo cardiovascular conocidos, y se les cuantifico el AS del ventriculo izquierdo. El valor promedio de AS fue –38,87 ± 5,89%. Los valores promedio a nivel de los segmentos basales, medio y apicales fueron –38,42 ± 7,58%, –38,74 ± 6,34% y –43,18 ± 12,81% respectivamente. Por lo tanto, nuestros resultados muestran, por primera vez, los valores de referencia de AS en sujetos sanos.

Background and Aim: Since the appearance of transesophageal echocardiography, the long-term prognosis of patients with negative blood culture infective endocarditis (NBCIE) has been found to be similar to that of patients with positive blood culture infective endocarditis (PBCIE). Nevertheless, the prognostic implications of NBCIE in the elderly (>65 years) has not, to date, been well documented. Our aim was to study the long-term prognosis of elderly patients with NBCIE and compare it with that of elderly patients with PBCIE. Methods: Our study group was composed of 60 consecutive patients >65 years old with a diagnosis of IE (confirmed by vegetation analysis or following Duke’s criteria). Every patient underwent transthoracic and transesophageal echocardiography. Fifty patients (83.3%) had PBCIE and 10 (16.7%) had NBCIE. All patients were followed up long-term, and the study end point was a composite one of death or need for valvular heart surgery. Results: Mean age was 72.9 ± 5 years (56.7% male). Similar clinical and echocardiographic characteristics were found in both groups. Global mortality, need for surgery, predisposing factors and infection location were also similar in both groups. In addition, no differences were found in the long-term prognosis (log rank p = 0.29). Conclusions: In our series, the long-term prognosis in elderly patients with IE is independent of the presence of a negative or positive blood culture. Thus, age cannot be considered an independent risk factor of negative outcome in elderly patients with NBCIE.

A feasibility study Leopoldo Perez de Isla ⁎, Vera Lennie , Maribel Quezada , Juan Guinea , Cristina Arce , Pilar Abad , Adriana Saltijeral , Nellys Carolina Campos , Jacobo Crespo , Borja Gonzalvez , Agustin Macia , Jose Zamorano d a Unidad de Imagen Cardiologica, Hospital Carlos III, Madrid, Spain b Cardiologia, Hospital del Tajo, Aranjuez, Madrid, Spain c Nuubo, Madrid, Spain d Unidad de Imagen Cardiovascular, Hospital Clinico San Carlos, Madrid, Spain

Objective: Pulmonary arterial hypertension (PAH) is a progressive, fatal disease with average survival of less than 3 years if left untreated. It is most common in patients infected with HIV. Although the pathogenesis in this population is not fully understood, it is thought that HIV infection, through the immune response and release of different inflammatory mediators such as endothelin-1, may contribute directly to endothelial damage. Our objective was to quantify endothelin-1 levels in HIV-infected patients and determine whether or not there is an association between this marker and PAH. Design: A case-control study in patients attending an infectious diseases clinic. Methods: The sample was composed of 79 patients divided into three groups: 23 HIV patients with PAH (HIV+/PAH+), 45 HIV patients without PAH (HIV+/PAH−) and a control group of 11 healthy individuals. The ratio between the HIV+/PAH− and HIV+/PAH+ groups was 2 : 1. Patients were matched by age, sex, risk group and viral load; the control group by age and sex. All patients had blood taken for endothelin-1 plasma quantification. Results: We found lower endothelin-1 levels in the controls than in the HIV+/PAH− group [0.71 pg/ml (interquartile range, IQR 0.54–0.94) vs. 1.13 pg/ml (IQR 0.87–1.38); P = 0.005] and the HIV+/PAH+ cohort [1.16 pg/ml (IQR 0.86–2.37); P = 0.003]. Patients with severe PAH had higher endothelin-1 levels [2.94 pg/ml (IQR 1.81–6.33)] than patients with mild and moderate PAH. Conclusion: Plasma endothelin-1 levels are higher in HIV patients with PAH than in the HIV-noninfected population and levels increase with the severity of the PAH.

This case report is about an 84-year-old woman admitted with right atrial thrombus attached to a pacemaker lead, diagnosed by transesophageal echocardiography. Surgical treatment was rejected due to the high operative risk, and percutaneous stenting was performed with success; unfortunately, the outcome was fatal and the patient died. We review here the clinical features of right atrial thrombi, including the epidemiology, clinical manifestations, diagnosis, and treatment, which is sometimes controversial.

SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD) REPRESENTS A DIAGNOSTIC CHALLENGE [(1,2)][1]. In this study, we used a combined imaging strategy, intravascular ultrasound (IVUS) and optical coherence tomography (OCT), in 8 patients with SCAD. The diagnosis of SCAD required the visualization of an

Background Pulmonary arterial hypertension (PAH) is uncommon among HIV-positive patients. However, it is a potentially life-threatening condition. Transthoracic echocardiography (TTE) is a noninvasive tool validated for PAH screening. The aim of our study was to establish the prevalence and factors associated with PAH in HIV-infected patients. Methods Consecutive HIV-infected individuals attended at one HIV reference clinic in Madrid, Spain, during year 2011 were examined. Demographics and clinical data were recorded and a Doppler echocardiography was performed in all individuals. PAH was considered when right ventricular pressure was more than 35 mmHg (mild if 65 mmHg). Results Three hundred and ninety-two individuals were examined (83.4% men, median age 47 years, 53% were men who have sex with men and 53% former intravenous drug addicts). Overall, 84% were on HAART, 76% had undetectable HIV viral load and median CD4 cell counts were 577 cells/μl. Cardiovascular risk factors were smoking 50%, arterial hypertension 16% and diabetes mellitus 9%. A total of 28.5 and 4.8% had chronic hepatitis C (CHC) and 4.8% chronic hepatitis B, respectively. PAH was diagnosed in 9.9% of patients (6.4% mild, 2.8% moderate and 0.8% severe). Multivariate logistic regression analysis [odds ratio (OR), 95% confidence interval (CI)] showed that detectable plasma HIV-RNA [OR, 3.3; 95% CI, 1.04-10], CHC [OR, 3.1; 95% CI 1.2-8.2] and female sex [OR, 2.9; 95% CI, 1.04-8.3] were independently associated with PAH. Conclusion The prevalence of PAH HIV-infected patients on regular follow-up approaches 10%, being moderate-severe in nearly 4% of cases. Patients with CHC and/or uncontrolled HIV replication exhibit a higher risk of PAH.

The echocardiographic technology known as three-dimensional wall motion tracking offers three-dimensional images of the myocardium and provides multiple measures of deformation, one of which is known as "area strain" (AS), which combines left ventricular longitudinal and circumferential deformations. Our aim was to describe the normal maximum systolic reference AS value in a sample of healthy subjects. Sixty consecutive subjects without known cardiovascular risk factors or diseases were enrolled, and left ventricular AS was measured. Overall mean AS was -38.87 ± 5.89%. Mean values at the level of the basal, middle, and apical segments were -38.42 ± 7.58%, -38.74 ± 6.34%, and -43.18 ± 12.81%, respectively. Thus, our results show for the first time the reference values for AS in healthy subjects.

Distortion of the terminal portion of the QRS in the initial electrocardiogram (ECG) is a strong predictor of adverse outcome in myocardial infarction. Our purpose is to assess the relationship of distortion of QRS and other ECG characteristics with older age.We analysed 634 consecutive patients (age 62.6 +/- 13.7, 77% male) admitted in the first 12 hours of ST-elevation myocardial infarction. Two groups of age were defined:75 years-old andor= 75 years-old. Additionally, we defined two ECG groups according to the presence of ST segment elevation with distortion of the terminal portion of the QRS in two or more adjacent leads (QRS+) or the absence of this pattern (QRS-). Older people had more often QRS+ (30% vs. 20%, p = 0.023). The older group with QRS+ had an in-hospital mortality of 18%, vs. 7% with QRS- (p = 0.04), and an incidence of major adverse events of 40% vs. 14% (p = 0.002). In the multivariate analysis, ageor= 75 years was an independent predictor of distortion of the QRS (odds ratio 2.1, 1.2-4.9, p = 0.016).The distortion of the terminal portion of the QRS in myocardial infarction is more frequent in elderly people, and is significantly related to adverse prognosis. This ECG finding can be helpful to promptly stratify the risk in elderly patients.

We read with great interest the elegant study by Saw et al. [(1)][1] that carefully described predisposing conditions in a large Canadian series of 50 patients with spontaneous coronary artery dissection (SCAD). Notably, fibromuscular dysplasia (FMD) in noncoronary territories was found in 86% of

An asymptomatic 55-year-old man with a previous history of hypertension and dyslipidaemia was referred to our clinic as a result of the finding of an enlarged cardiac silhouette in a routine chest radiography. His physical examination and electrocardiogram was unremarkable. Transthoracic echocardiogram revealed …